Western Health Advantage
methotrexate sodium (PF) (methotrexate sodium (PF))
Drugs for Cancer : Drugs for Cancer
  • May be covered under Medical Benefit.
  • Quantity Limit: 3 tablets per 1 day(s).
  • Prior Authorization: Diabetic Retinopathy, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Myopic Choroidal Neovascularization (mCNV):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 3 Month(s)
    Reauthorization Required: Yes

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